Independent investigation: Prodip Debnath, Mile End (2010)

It is recommended that the Trust develops and implements an Objective Structured Clinical Examination (OSCE) framework for the assessment of particular competencies such as observations, medical devices, physical health and medication administration. The further development of Reflective Practice Groups should also be considered.

It is recommended that serious consideration is given by the Trust to develop and implement single sex inpatient services.

It is recommended that the Trust devises a system whereby key information about patients is communicated to all staff on duty at any given time and that this follows a standardised, structured and documented process.

It is recommended that all transfers of patients should follow a comprehensive protocol that sets out a checklist that is audited on a regular basis to include: Risk analysis and management. Level of Observations. Management Plan. Physical Health. Medication Concordance History. Allocation of Primary Nurse Role. Diagnosis. Health care needs.

It is recommended that the Trust liaise with their designated fire safety officers and estates department to undertake an environmental risk assessment in order to ascertain whether it would be desirable or feasible to alter the opening mechanisms of the bedroom doors on ward A, and to provide the Trust with an assurance that the exit routes from the bedroom area are adequate in the event of a fire.

It is recommended that the Trust reviews its clinical lead process on each ward and sets out a clear structure of responsibilities and the procedure to report concerns through the Trust’s governance system. All concerns should be documented, with agreed outcomes and the process to achieve these monitored and reported back to the relevant professionals/service areas.

It is recommended that the Trust considers setting up their own interpreting services which could include those staff already employed to provide this additional expertise. It may be advantageous to involve other local Mental Health Trusts in this initiative.

It is recommended that there is a review of the job descriptions of the modern matron and practice innovation nurse that clarifies the individual roles and allocates different responsibilities within each. In addition the Trust should consider reverting back to the title of ward manager for one of these roles.

It is recommended that the Trust further review their observation policy to include supervision of the person conducting observations and changing the format of their observation form to ensure that: Clarity in regard to observation responsibility is added and staff responsible for the agreed tasks are identified and documented on the form. A robust competency framework is implemented for measuring the ability of nursing staff to carry out this intervention safely. A senior member of staff agrees and approves that the observations have been completed and signs the form appropriately. That qualified nursing staff undertake a minimum of one third of the observations within a shift.

It is recommended that the Trust gives serious consideration to the implementation of a Functional Team Model by discussing the process with their colleagues in neighbouring Trusts, medical professional bodies and their own consultant body. The opinion of other professionals such as nursing should also be sought and evaluation of the pilot model in Hackney undertaken.

It is recommended that any future incidents of this type and subsequent police investigation should be conducted under the auspices of the National Memorandum of Understanding and that the Trust ensures that the National Memorandum of Understanding is attached as a standard Appendix to their Serious Incident Policy and included in staff training into the use of the policy.

It is recommended that if a referral for an assessment is made to the Home Treatment Team then either a comprehensive assessment is undertaken or the reasons why not are communicated to the referrer and documented in the patient’s record within 24 hours.

It is recommended that the Trust and their local police force should agree the criteria and level of service that can be provided to the Trust in terms of on-call and out of hours support to Trust members of staff when an assault on either another patient or member of staff has occurred. In addition the organisations should also ensure that proper training is given to those officers likely to be asked to attend incidents at the Trust.

It is recommended that when a referral is made to the Home Treatment Team that the referrer is informed of the actions taken within 24 hours and that these are documented in the relevant patient records.